NCLEX-Question-2-001
A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority?
- A. Impaired urinary elimination related to fluid loss
- B. Ineffective airway clearance related to edema
- C. Disturbed body image related to physical appearance
- D. Risk for infection related to epidermal disruption
Correct Answer: B. Ineffective airway clearance related to edema
Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Exposure to materials burn can cause inhalation injury.
- Option A: Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops. Late-onset renal failure is usually the consequence of sepsis and is often associated with other organ failure.
- Option C: Burn injuries are among the most serious causes of radical changes in body image. The subject of body image and self-image is essential in rehabilitation, and the nurse must be aware of the issues related to these concepts and take them seriously into account in drafting out the nursing programme.
- Option D: Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.
NCLEX-Question-2-002
A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
- A. Temperature of 102°F (38.9° C)
- B. Worsening dyspnea
- C. Gastric distension
- D. Nausea and vomiting
Correct Answer: B. Worsening dyspnea
Dyspnea and other signs of respiratory distress signify fluid volume excess (overload), which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. The excess fluid circulating around the body can cause water logging of the lungs, leading to breathlessness. If fluid overload goes on for a long term it eventually leads to heart failure.
- Option A: An elevated temperature may indicate a fluid volume deficit. Hypohydration increases heat storage by reducing sweating rate and skin blood flow responses for a given core temperature. Hypertonicity and hypovolemia both contribute to reduced heat loss and increased heat storage.
- Option C: Gastric distention may suggest excessive oral fluid intake or infection. Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth of the stomach and waist. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right.
- Option D: Conditions that cause blood or body fluid loss can cause hypovolemia, as can inadequate fluid intake. If persistent or severe, diarrhea and vomiting can deplete body fluids. All living organisms must maintain an adequate fluid balance to preserve homeostasis. Water constitutes the most abundant fluid in the body, at around 50% to 60% of the body weight.
NCLEX-Question-2-003
Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?
- A. Absence of intercostals or substernal retractions
- B. Oxygen saturation of 95%
- C. Mild work of breathing
- D. History of steroid-dependent asthma
Correct Answer: D. History of steroid-dependent asthma
A history of steroid-dependent asthma, a contributing factor to this client’s high-risk status, requires the nurse to treat the situation as a severe exacerbation regardless of the severity of the current episode. Because of severe adverse effects of steroids, these patients are in need of therapies that can minimize their steroid requirements and control their asthma.
- Option A: Intercostal retractions are due to reduced air pressure inside the chest. This can happen if the upper airway (trachea) or small airways of the lungs (bronchioles) become partially blocked. Therefore, the absence of these findings indicates normal airways.
- Option B: Although an SpO2 <95% is considered abnormal in the CTAS and in most asthma and pneumonia guidelines, there is no description of the standard value. Furthermore, although conventional wisdom states that pulse oximetry levels ≥95% should be considered normal, data from previous studies suggest that the normal oxygen saturation range should lie between 97% and 100%. Therefore, oxygen saturation levels of 95% and 96% in school-aged children may correlate with an increased risk of an underlying clinical disease.
- Option C: Mild work of breathing is a normal finding. During acute exacerbations, children may have significantly increased work of breathing or audible wheezing, which may be appreciated by caregivers and prompt presentation for further evaluation.
NCLEX-Question-2-004
Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
- A. Obtaining skull X-ray
- B. Measuring head circumference
- C. Performing a lumbar puncture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B. Measuring head circumference
Measuring head circumference is the most important assessment technique for recognizing possible hydrocephalus, and is a key part of routine infant screening. Congenital hydrocephalus is usually present at birth. An unusually large head is a significant sign of congenital hydrocephalus.
- Option A: X-rays of the skull may show erosion of sella turcica, or so-called “beaten copper cranium” appearance, but are seldom helpful or indicated with the availability of better imaging techniques. Ultrasonography through anterior fontanelle may be used in infants for evaluating the ventricular system and progression of hydrocephalus.
- Option C: A lumbar puncture isn’t appropriate. CSF analysis could be done to help with the diagnosis and to exclude residual infection. Neuroimaging plays a central role in confirming the diagnosis in suspected cases, identifying the cause and possible treatment. In cases of acute hydrocephalus, an emergency head computed tomographic (CT) scan is the first option to assess the ventricular size.
- Option D: MRI may be used to confirm the diagnosis. Magnetic resonance imaging (MRI) of the brain is the study of choice as it shows better the posterior fossa structures, can differentiate between brain tumors and degenerative diseases and can differentiate NPH from cerebral atrophy.
NCLEX-Question-2-005
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?
- A. Apply hydrocortisone cream under the cast using sterile applicator
- B. Apply cool air under the cast with a blow-dryer
- C. Use sterile applicators to scratch the itch
- D. Apply cool water under the cast
Correct Answer: B. Apply cool air under the cast with a blow-dryer
Itching underneath a cast can be relieved by directing the blow-dryer, set, on the cool setting, toward the itchy area. Therefore, one of the best ways to relieve moisture is, of course, to dry it off. The client may find ways to blow cool air into and through the cast. The client may be able to do that using specific settings on a hairdryer, for example.
- Option A: Do not stick objects such as coat hangers inside the splint or cast to scratch itching skin. Do not apply powders or deodorants to itching skin. If itching persists, contact a doctor.
- Option C: Skin breakdown can occur if anything is placed under the cast. Therefore, the client should be cautioned not to put any object down the cast in an attempt to scratch. Scratching in this way could lead to an open wound or developing sores.
- Option D: Moisture weakens plaster and damp padding next to the skin can cause irritation. Use two layers of plastic or purchase waterproof shields to keep the splint or cast dry while showering or bathing.
NCLEX-Question-2-006
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first?
- A. Assess vital signs
- B. Institute seizure precautions
- C. Assess neurologic status
- D. Place in respiratory isolation
Correct Answer: D. Place in respiratory isolation
The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy, and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection. The patient with suspected or confirmed N. meningitidis should follow droplet precaution. This should be continued until after 24 hours of effective antibiotics administration.
- Option A: Prompt recognition and immediate initiation of treatment are of utmost importance in the management of bacterial meningitis.Patients can present with abnormal vital signs, including fever, tachypnea, tachycardia, and hypotension. Hypotension with elevated pulse rate is suggestive of early vascular instability.
- Option B: Complications of meningococcal meningitis can arise early or late in the disease course and can adversely impact morbidity and mortality.Late complications of meningococcal meningitis include chronic pain, skin scarring, and neurologic impairment. Other common complications include hearing impairment, visual impairment, and seizures.
- Option C: Assessment should be performed after the patient is placed on respiratory isolation in order to avoid infecting other patients. Prompt antibiotic administration, especially within one hour, has been proven to improve morbidity and mortality, as well as prevent complications such as increased intracranial pressure and septic shock.
NCLEX-Question-2-007
A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?
- A. Reverse isolation
- B. Respiratory isolation
- C. Contact isolation
- D. Standard precautions
Correct Answer: C. Contact isolation
Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin-resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient’s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia.
- Option A: Reverse isolation refers to the practice of healthcare workers and visitors wearing barriers (i.e., gown, gloves, mask, etc.) routinely upon entry to the client room, for the purpose of preventing client exposure to external microbes. Certain immunocompromised clients have been shown to benefit from specific additional “interventions”. These interventions create a “Protective Environment”.
- Option B: Respiratory isolation is used for diseases that are spread through particles that are exhaled. Those having contact with or exposure to such a patient are required to wear a mask. Respiratory isolation guidelines for patients admitted from the ED with pneumonia were developed and validated in a study. These guidelines provide satisfactory guidance for isolation of patients at risk for PTB in a high-TB-prevalence population.
- Option D: Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect DHCP and prevent DHCP from spreading infections among patients.
NCLEX-Question-2-008
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions?
- A. A diagnosis of AIDS and cytomegalovirus
- B. A positive PPD with an abnormal chest x-ray
- C. A tentative diagnosis of viral pneumonia
- D. Advanced carcinoma of the lung
Correct Answer: B. A positive PPD with an abnormal chest x-ray
The client who must be placed in airborne precautions is the client with a positive PPD (purified protein derivative) who has a positive x-ray for a suspicious tuberculin lesion. Airborne precautions are required whenever entering a patient’s room or environment who has been diagnosed with or is being tested for with high suspicion of anthrax, tuberculosis, measles, chickenpox, or disseminated herpes zoster or other pathogens that can be transmitted through airflow that are 5 micrometers or smaller in size and remain in the environment for long periods of time.
- Option A: According to the OSHA database, HIV, hepatitis B and C, tuberculosis, malaria, measles, herpes, chickenpox, and various other bacterial infections are known for being transmitted through blood-containing fluids and products. Blood-borne precautions include wearing gloves, face mask, protective eyewear or goggles, and proper handling of sharp objects with appropriate disposal.
- Option C: Prevention, especially in the form of immunization against influenza and measles, can significantly decrease the incidence of viral pneumonia. The traditional role of viral pneumonia was as a disease found predominantly in the very young, the elderly, and those exposed to influenza. In the past, the diagnosis of viral pneumonia was predicated on it being somewhat a diagnosis of exclusion.
- Option D: Smoking is the most common cause of lung cancer. It is estimated that 90% of the cases of lung cancer are attributable to smoking. The risk is highest in males who smoke. The risk is further compounded with exposure to other carcinogens, such as asbestos. It is hypothesized that repeated exposure to carcinogens, cigarette smoke, in particular, leads to dysplasia of lung epithelium.
NCLEX-Question-2-009
Which of the following is the first priority in preventing infections when providing care for a client?
- A. Wearing gowns and goggles
- B. Using a barrier between client’s furniture and nurse’s bag
- C. Handwashing
- D. Wearing gloves
Correct Answer: C. Handwashing
Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client and before entering the nursing bag.
- Option A: Isolation gowns are generally the preferred PPE for clothing but aprons occasionally are used where limited contamination is anticipated. If contamination of the arms can be anticipated, a gown should be selected. Goggles provide barrier protection for the eyes; personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles.
- Option B: In terms of airflow blocking, a barrier height of at least 40 cm above the desk level (at 80 cm) is recommended to prevent the coughing flow of an infected person, considering an unknown location in the open office and subject to a modified ventilation mode.
- Option D: Gloves are the most common type of PPE used in healthcare settings. However, gloves should never replace the practice of handwashing. The nurse should learn to work from clean to dirty. This is a basic principle of infection control. In this instance, it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas.
NCLEX-Question-2-010
An adult woman is admitted to an isolation unit in the hospital after tuberculosis was detected during a pre-employment physical. Although frightened about her diagnosis, she is anxious to cooperate with the therapeutic regimen. The teaching plan includes information regarding the most common means of transmitting the tubercle bacillus from one individual to another. Which contamination is usually responsible?
- A. Eating utensils
- B. Hands
- C. Milk products
- D. Droplet nuclei
Correct Answer: D. Droplet nuclei.
The most frequent means of transmission of the tubercle bacillus is by droplet nuclei. The bacillus is present in the air as a result of coughing, sneezing, and expectoration of sputum by an infected person. Although usually a lung infection, tuberculosis is a multi-system disease with protean manifestation. The principal mode of spread is through inhalation of infected aerosolized droplets.
- Option A: The tubercle bacillus is not transmitted by eating utensils. Some exogenous microbes can be transmitted via reservoirs such as linens or eating utensils. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, speaks, or sings. People nearby may breathe in these bacteria and become infected.
- Option B: Hands are the primary method of transmission of the common cold. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. From there, they can move through the blood to other parts of the body, such as the kidney, spine, and brain.
- Option C: The tubercle bacillus is not transmitted by means of contaminated food. Contact with contaminated food or water could cause outbreaks of salmonella, infectious hepatitis, typhoid, or cholera.
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NCLEX-Question-2-011
A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?
- A. Place a urine collection bag and specimen cup at the bedside
- B. Order a stat admission CBC
- C. Pad the side rails of his bed
- D. Place a cooling mattress on his bed
Correct Answer: C. Pad the side rails of his bed
The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence. Febrile seizure status is defined as a seizure lasting longer than 30 minutes. Therefore, prompt treatment of prolonged seizures of a febrile nature is as necessary as prompt treatment of prolonged seizures arising from other etiologies.
- Option A: Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A patient with a normal general and neurologic exam, whose history is consistent with a simple febrile seizure, does not need a further laboratory, imaging, or neurophysiologic evaluation.
- Option B: Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A lumbar puncture may be a consideration in the setting of fever and seizures. For a patient with the appropriate history of a febrile seizure and a rapid return to baseline, no lumbar puncture is necessary.
- Option D: A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. There is no specific treatment for simple or complex febrile seizures other than appropriate treatment for underlying etiologies driving the ongoing febrile illness. Antipyretics have not been shown to prevent a recurrence of febrile seizures.
NCLEX-Question-2-012
A young adult is being treated for second and third-degree burns over 25% of his body and is now ready for discharge. The nurse evaluates his understanding of discharge instructions relating to wound care and is satisfied that he is prepared for home care when he makes which statement?
- A. “I will need to take sponge baths at home to avoid exposing the wounds to unsterile bathwater.”
- B. “I can expect occasional periods of low-grade fever and can take Tylenol every 4 hours.”
- C. “I must wear my Jobst elastic garment all day and can only remove it when I’m going to bed.”
- D. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
Correct Answer: D. “If any healed areas break open I should first cover them with a sterile dressing and then report it.”
The client is taught to report changes in wound healing such as blister formation, signs of infection, and opening of a previously healed area. Sterile dressings are applied until the wound is assessed and a plan of care developed. While many factors must be considered in dressing selection, the goals in selecting the most appropriate dressing should include providing protection from contamination (bacterial or otherwise) and from physical damage, allowing gas exchange and moisture retention, and providing comfort to enhance functional recovery.
- Option A: Bathing or showering in the usual manner is permitted, using a mild detergent soap such as Ivory Snow. This cleanses the wounds, especially those that are still open and removes dead tissue.
- Option B: The client must be aware that infection of the wound may occur; signs of infection, including fever, redness, pain, warmth in and around the wound and increased or foul-smelling drainage must be reported immediately.
- Option C: The Jobs garment is designed to place constant pressure on the new healthy tissue that is forming to promote adherence to the underlying structure in order to prevent hypertrophic scarring. In order to be effective, the garment must be worn for 23 hours daily. It is removed for wound assessment and wound care and to permit bathing.
NCLEX-Question-2-013
An eighty five year old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is:
- A. Speak soothingly and provide quiet music
- B. Encourage family phone calls
- C. Limit visits by staff
- D. Position in a bright, busy area
Correct Answer: A. Speak soothingly and provide quiet music
The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops a feeling of security in the presence of a calm staff person.
- Option B: Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client.
- Option C: The client needs frequent visits by the staff to orient him and to assess his safety. The client’s safety is utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
- Option D: Putting the client in a bright, busy area would probably add to his confusion. Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.
NCLEX-Question-2-014
Ms. Smith is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?
- A. She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.”
- B. “I understand it will be several weeks before all the radiation leaves my body.”
- C. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
- D. “I brought several craft projects to do while the radium is inserted.”
Correct Answer: C. “I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.”
People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus. This statement is not true. The radiation doesn’t travel very far from the treatment area. So it is usually safe to be with other people. However, as a precaution, the client will need to avoid very close contact with children and pregnant women for a time.
- Option A: The client will be on a clear liquid or very low residue diet. Hamburgers and french fries are not allowed. Foods to avoid or reduce during radiation therapy include sodium (salt), added sugars, solid (saturated) fats, and an excess of alcohol. Some salt is needed in all diets.
- Option B: As soon as the radiation source is removed, the client is no longer contaminated with radioactivity. The radiation stays in the body for anywhere from a few minutes to a few days. Most people receive radiation therapy for just a few minutes. Sometimes, people receive internal radiation therapy for more time. If so, they stay in a private room to limit other people’s exposure to the radiation.
- Option D: Craft projects usually require the client to sit. The client must remain flat with very little head elevation during the time the rods are in place. Treatment planning usually involves positioning the body, making marks on the skin and taking imaging scans. The radiation therapy team determines whether the client will lie on their back, stomach or side during treatment.
NCLEX-Question-2-015
The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?
- A. The nurse puts on a mask, a gown, and gloves before entering the room of a client in strict isolation.
- B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
- C. The nurse aide is not wearing gloves when feeding an elderly client.
- D. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
Correct Answer: B. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves. Strict isolation requires the use of a mask, gown, and gloves. Personnel involved in treating high-risk infections should be specialized in isolation work and be healthy, not immunosuppressed, and if possible should be vaccinated, if a vaccine is available.
- Option A: Strict isolation refers to suspected highly infectious and transmissible virulent and pathogenic microbes, highly resistant bacterial strains and agents that are not accepted in any form of distribution in the society or in the environment. Patients in need of strict isolation should be placed in a separate isolation ward or building.
- Option C: There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations.
- Option D: A client with active tuberculosis should be on respiratory precautions. Airborne precautions are used in addition to standard precautions to prevent disease transmission from individuals known or suspected to have diseases spread by fine particles, including, TB.
NCLEX-Question-2-016
The charge nurse observes a new staff nurse who is changing a dressing on a surgical wound. After carefully washing her hands the nurse dons sterile gloves to remove the old dressing. After removing the dirty dressing, the nurse removes the gloves and dons a new pair of sterile gloves in preparation for cleaning and redressing the wound. The most appropriate action for the charge nurse is to:
- A. Discuss dressing change technique with the nurse at a later date.
- B. Congratulate the nurse on the use of good technique.
- C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
- D. Interrupt the procedure to inform the staff nurse that sterile gloves are not needed to remove the old dressing.
Correct Answer: C. Interrupt the procedure to inform the nurse of the need to wash her hands after removal of the dirty dressing and gloves.
The staff nurse is doing two things incorrectly. Nonsterile gloves are adequate to remove the old dressing. The nurse should wash her hands after removing the soiled dressing and before donning sterile gloves to clean and dress the wound. Not doing this compromises client safety and should be brought to the immediate attention of the nurse.
- Option A: Before discussion of dressing technique with the staff nurse, the charge nurse should ensure that the new nurse knows the proper infection control technique during dressing changes to prevent contaminating the client’s surgical wound.
- Option B: Approval of an inappropriate technique would not lead to necessary changes.The new staff nurse needs further education on how to properly handle dressing changes for a surgical wound, especially the proper infection control techniques. If the new staff nurse demonstrates correct infection control technique and proper dressing changes, then the charge nurse may offer them praise for their work and diligence.
- Option D: Nonsterile gloves are adequate to remove the old dressing. However, the use of sterile gloves does not put the client in danger so discussion of this can wait until later. Proper infection control technique is of utmost importance during dressing changes of a surgical wound to avoid complications.
NCLEX-Question-2-017
Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is:
- A. Correct illumination of the environment
- B. Amount of regular exercise
- C. The resting pulse rate
- D. Status of salt intake
Correct Answer: A. Correct illumination of the environment
To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Providing lighting in key places can reduce fall risk and avoid obstacles during mobility. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate.
- Option B: Exercises can improve muscle strength, balance, coordination, and reaction time. Physical conditioning reduces the incidence of falls and avoids injury that is sustained when a fall happens.However, the amount of regular exercise is not the most important factor to assess. It is only indirectly related.
- Option C: The resting pulse rate is not related to preventing falls. Instead, place assistive devices and commonly use items within reach. This provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
- Option D: The salt intake is not directly related to preventing falls. Instead, advise the client to wear shoes or slippers with non-slip soles when walking. Wearing non-slip footwear helps prevent slips and falls.
NCLEX-Question-2-018
Mrs. Jones will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. Jones understands the importance of maintaining asepsis?
- A. “If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.”
- B. “If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.”
- C. “If I question the sterility of any dressing material, I should not use it.”
- D. “I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.”
Correct Answer: C. “If I question the sterility of any dressing material, I should not use it.”
If there is ever any doubt about the sterility of an instrument or dressing, it should not be used. Sterile technique is essential to help prevent surgical site infections (SSI), an unintended and oftentimes preventable complication arising from surgery. SSI is defined as an “infection that occurs after surgery in the area of surgery” (CDC, 2010, p. 2).
- Option A: Anything dropped on the floor is no longer sterile and should not be used. The statement indicates lack of understanding. Preventing and reducing SSI are the most important reasons for using sterile technique during invasive procedures and surgeries.
- Option B: The 4 X 4s should be soaked prior to donning the sterile gloves. Normal saline would not keep the gauze sterile after being dropped on the floor. The client would need to replace the unsterile gauze with a new, sterile pack.
- Option D: Once the sterile gloves touch the bottle of normal saline they are no longer sterile. This statement indicates a need for further instruction. Sterile objects must only be touched by sterile equipment or sterile gloves.
NCLEX-Question-2-019
A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?
- A. Masks should be worn with all client contact
- B. A private room is always indicated
- C. Isolation gowns are not needed
- D. Gloves should be worn for contact with non intact skin, mucous membranes, or soiled items
Correct Answer: D. Gloves should be worn for contact with nonintact skin, mucous membranes, or soiled items.
Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items; and for performing venipuncture. These precautions treat all blood and body fluids as potentially infectious for diseases that are transmitted in the blood. The organisms spreading these diseases are called blood-borne pathogens.
- Option A: Masks should only be worn during procedures that are likely to cause splashes of blood or body fluid. Masks and protective eyewear, such as goggles or a face shield, help protect the eyes, mouth, and nose from droplets of blood and other body fluids. Always wear a mask and protective eyewear if doing a procedure that may expose oneself to splashes or sprays of blood or body fluids.
- Option B: A private room is only indicated if the client’s hygiene is poor. Blood and body fluid precautions are recommendations designed to prevent the transmission of HIV, hepatitis B, hepatitis C, and other diseases while giving first aid or other health care that includes contact with body fluids or blood.
- Option C: Gowns should be worn during procedures that are likely to cause splashes of blood or body fluids. Gowns or aprons protect the personnel from splashes of blood or body fluids. Always wear a gown or apron if doing a procedure that may expose oneself to splashes or sprays of blood or body fluids.
NCLEX-Question-2-020
The nurse is evaluating whether nonprofessional staff understand how to prevent transmission of HIV. Which of the following behaviors indicates correct application of universal precautions?
- A. An aide wears gloves to feed a helpless client.
- B. A pregnant worker refuses to care for a client known to have AIDS.
- C. A lab technician rests his hand on the desk to steady it while recapping the needle after drawing blood.
- D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.
Correct Answer: D. An assistant puts on a mask and protective eyewear before assisting the nurse to suction a tracheostomy.
Masks and protective eyewear are indicated anytime there is great potential for splashing of body fluids that may be contaminated with blood. Suctioning of a tracheostomy almost always stimulates coughing, which is likely to generate droplets that may splash the health care worker. Clients who are suctioned frequently or have had an invasive procedure like a tracheostomy are likely to have blood in the sputum.
- Option A: Gloves are not necessary when feeding, since there is no contact with mucous membranes. Although saliva may have small amounts of HIV in it, the virus does not invade through unbroken skin. There is no evidence in the question to indicate broken skin.
- Option B: There is no reason to restrict pregnant workers from caring for persons with AIDS as long as they utilize universal precautions. Use new gloves for every patient. Wear protective eyewear, masks, or face shields (with safety glasses or goggles) during procedures likely to generate droplets of blood or body fluids. In general, protective eyewear, masks, and clothing are not needed for routine care of AIDS virus-infected persons.
- Option C: Needles that have been used to draw blood should not be recapped. If it is necessary to recap them, an instrument such as a hemostat should be used to recap. The hand should never be used.
NCLEX-Question-2-021
Jayson, a 1 year old child has a staph skin infection. Her brother has also developed the same infection. Which behavior by the children is most likely to have caused the transmission of the organism?
- A. Sharing pacifiers
- B. Coughing on each other
- C. Bathing together
- D. Eating off the same plate
Correct Answer: C. Bathing together.
Direct contact is the mode of transmission for staphylococcus. S. aureus are one the most common bacterial infections in humans and are the causative agents of multiple human infections, including bacteremia, infective endocarditis, skin and soft tissue infections (e.g., impetigo, folliculitis, furuncles, carbuncles, cellulitis, scalded skin syndrome, and others), osteomyelitis, septic arthritis, prosthetic device infections, pulmonary infections (e.g., pneumonia and empyema), gastroenteritis, meningitis, toxic shock syndrome, and urinary tract infections.
- Option A: S. aureus does not normally cause infection on healthy skin, however, if it is allowed to enter the internal tissues or bloodstream, these bacteria may cause a variety of potentially serious infections. Depending on the strains involved and the site of infection, these bacteria can cause invasive infections and/or toxin-mediated diseases.
- Option B: S. aureus is not spread through droplets or airborne means.Staphylococcus aureus (including drug-resistant strains such as MRSA) are found on the skin and mucous membranes, and humans are the major reservoir for these organisms. It is estimated that up to half of all adults are colonized, and approximately 15% of the population persistently carry S. aureus in the anterior nares.
- Option D: Prevention of S. aureus infections remains challenging. Despite many efforts, a routine vaccination for S. aureus infections has remained elusive. As a result, efforts have relied on infection control methods such as hospital decontamination procedures, handwashing techniques, and MRSA transmission prevention guidelines.
NCLEX-Question-2-022
Jessie, a young man with newly diagnosed acquired immune deficiency syndrome (AIDS) is being discharged from the hospital. The nurse knows that teaching regarding prevention of AIDS transmission has been effective when the client:
- A. Verbalizes the role of sexual activity in the spread of the disorder.
- B. States he will make arrangements to drop his college classes.
- C. Acknowledges the need to avoid all contact sports.
- D. Says he will avoid close contact with his three-year-old niece.
Correct Answer: A. Verbalizes the role of sexual activity in the spread of the disorder.
HIV is spread through direct contact with body fluids such as blood and through sexual intercourse. Casual contact with other people does not pose a risk of transmission of HIV. Review modes of transmission of disease, especially if newly diagnosed. This corrects myths and misconceptions; promotes safety for the client and others. Accurate epidemiological data are important in targeting prevention interventions.
- Option B: Unless the client is feeling very ill, there is no need for him to drop his college classes. Determine level of independence or dependence and physical condition. Note extent of care and support available from family and SO and need for other caregivers.
- Option C: Contact sports are not contraindicated unless there is a significant chance of bleeding and direct contact with others. Casual contact with other people does not pose a risk of transmission of HIV.
- Option D: There is no need to limit casual contact with children. The nurse may discuss extent and rationale for isolation precautions and maintenance of personal hygiene. This may promote cooperation with the regime and may lessen feelings of isolation.
NCLEX-Question-2-023
Which question is least useful in the assessment of a client with AIDS?
- A. Are you a drug user?
- B. Do you have many sex partners?
- C. What is your method of birth control?
- D. How old were you when you became sexually active?
Correct Answer: D. How old were you when you became sexually active?
The age at which sexual activity began is not relevant as it does not usually provide information that identifies the presence of risk factors for AIDS. A large number of patients may only have an asymptomatic infection after the exposure. The usual time from exposure to onset of symptoms is 2 to 4 weeks, although, in some cases, it can be as long as 10 months.
- Option A: Drug use is a risk factor for AIDS where people can get the disease by sharing the needles or equipment with an infected individual. In the United States, a critical risk factor for HIV propagation among young people is the use of drugs before having sex, including marijuana, alkyl nitrites (“poppers”), cocaine, and ecstasy.
- Option B: Multiple sex partners is a risk factor for AIDS. Other risk factors associated with acquiring HIV infection include men who have sex with men, unsafe sexual practices, the use of intravenous drugs, vertical transmission, and blood transfusions or blood products.
- Option C: Birth control methods are important to prevent a baby from being born with the AIDS virus. Use a clean condom at all times when having sexual intercourse. Preferably use a condom that contains a water-based lubricant, which is more protective.
NCLEX-Question-2-024
Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse’s preoperative goals for Mrs. M. would include:
- A. Independently ambulating around the unit
- B. Reading the routine preoperative education materials
- C. Maneuvering safely after orientation to the room
- D. Using a bedpan for elimination needs
Correct Answer: C. Maneuvering safely after orientation to the room.
Maneuvering safely after orientation to the room is a realistic goal for a person with impaired vision. Orienting the client to the room should help the client to move safely. The client should be familiarized with the bed, location of the bathroom, furniture, and other environmental hazards that can cause older patients to trip or fall.
- Option A: Independently ambulating around the unit is not appropriate because the unit environment can change and injury could result. Place assistive devices and commonly use items within reach. This provides easy access to assistive devices and personal care items. Items such as call bell, telephone, and water should be kept close to avoid frequent reaching.
- Option B: Assistance is necessary because of the client’s visual deficit. It is unlikely the client can see well enough to read the materials. Ensure the client’s eyesight is regularly checked and explain the importance of wearing eyeglasses if needed. Make sure glasses and hearing aids are always worn.
- Option D: Using the bedpan is an unnecessary restriction on the client as she can be oriented to the bathroom or to call for assistance. Instruct the client how to ambulate at home, including using safety measures such as handrails in the bathroom.
NCLEX-Question-2-025
A child is undergoing remission induction therapy to treat leukemia. Allopurinol is included in the regimen. The main reason for administering allopurinol as part of the client’s chemotherapy regimen is to:
- A. Prevent metabolic breakdown of xanthine to uric acid
- B. Prevent uric acid from precipitating in the ureters
- C. Enhance the production of uric acid to ensure adequate excretion of urine
- D. Ensure that the chemotherapy doesn’t adversely affect the bone marrow
Correct Answer: A. Prevent metabolic breakdown of xanthine to uric acid
The massive cell destruction resulting from chemotherapy may place the client at risk for developing renal calculi; adding allopurinol decreases this risk by preventing the breakdown of xanthine to uric acid. These clients can have increased uric acid levels due to release of uric acid from the dying cancer cells.
- Option B: Allopurinol and oxypurinol both inhibit xanthine oxidase, an enzyme in the purine catabolism pathway that converts hypoxanthine to xanthine to uric acid. Allopurinol undergoes metabolism in the liver, where it transforms into its pharmacologically active metabolite, oxypurinol.
- Option C: Urate production is accelerated by purine-rich diets, endogenous purine production, and high cell breakdown, and it is responsible for a minority of cases of hyperuricemia. Foods rich in purine include all meats but specifically organ meats (kidneys, liver, “sweet bread”), game meats, and some seafood (anchovies, herring, scallops).
- Option D: Allopurinol doesn’t act in the manner described in this option. To prevent tumor lysis syndrome, allopurinol shall be initiated 2 to 3 days before starting chemotherapy and continued until 3 to 7 days after chemotherapy.